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Macular hemorrhage after laser in situ keratomileusis for high myopia
case reports
Macular hemorrhage after laser in situ keratomileusis for high myopia Pierre Ellies, MD, Dominique Pietrini, MD, Livia Lumbroso, MD, Dan A. Lebuisson, MD ABSTRACT We describe 2 women with high myopia of ⫺12.0 and ⫺18.0 diopters who presented with myopic macular hemorrhages 1 and 4 days, respectively, after being treated by laser in situ keratomileusis (LASIK). One hemorrhage was related to a pre-existing choroidal neovascularization and the other to the presence of lacquer cracks. The hemorrhages resolved but resulted in a permanent decrease in vision. A careful fundus examination should be conducted before performing LASIK in highly myopic patients. In cases of similar macular pathology, fluorescein angiography should be done before LASIK. J Cataract Refract Surg 2000; 26:922–924 © 2000 ASCRS and ESCRS
L
aser in situ keratomileusis (LASIK) for high myopia is associated with complications such as a higher incidence of regression and undercorrection. Late appearance of a pseudokeratoconus can be seen. However, macular hemorrhage after LASIK is rare. To the best of our knowledge, although the complication has been reported, it has not been fully described. We present 2 highly myopic patients who developed macular hemorrhages 2 and 6 days, respectively, after LASIK.
Case Reports Both patients had LASIK with an ALK E microkeratome (Chiron), a vacuum pressure of 25 mm Hg, and a suction ring Accepted for publication December 1, 1999. From the Department of Ophthalmology, Hoˆtel-Dieu de Paris Hospital (Ellies), Clinique de la Vision (Pietrini), and Department of Ophthalmology, Pitie´-Salpe´trie`re Hospital, Paris (Lumbroso), and Department of Ophthalmology, Foch Hospital, Suresnes (Lebuisson), France. None of the authors has a financial or proprietary interest in any material or method mentioned. Reprint requests to D. Pietrini, MD, Clinique de la Vision, 55 Avenue Hoche, 75008 Paris, France. E-mail: [email protected]. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
applied until intraocular pressure (IOP) was greater than 65 mm Hg. Two types of laser were used: Case 1, the MEL 60 (Meditec); Case 2, the Keracor 117 (Chiron). A complete ophthalmic examination and corneal videotopography were performed before surgery. Both patients had generalized thinning of the retinal pigment epithelium (RPE), which is characteristic of a myopic fundus.
Case 1 A 32-year-old woman had LASIK in the left eye to correct myopia in May 1996. Best corrected visual acuity (BCVA) before surgery was 20/50 with a correction of ⫺18.0 diopters (D). Preoperative pachymetry was 570 m, and stromal ablation depth was 170 m. Four days after LASIK, the patient had a severe loss of visual acuity in the left eye; BCVA was worse than 20/200. A submacular hemorrhage could be seen on fundoscopy. Fluorescein angiography revealed an area of blocked choroidal and retinal fluorescence corresponding to the hemorrhage (Figure 1). An indocyanine green angiography showed no evidence of choroidal neovascularization. Fluorescein angiography performed 1 month later revealed macular lacquer cracks at the site of the previous hemorrhage and no evidence of subretinal neovascularization. The macular hemorrhage had disappeared (Figure 2). Six months later, BCVA was 20/80 and the fundus unchanged. 0886-3350/00/$–see front matter PII S0886-3350(00)00313-8
CASE REPORTS: ELLIES
proximately 300 m (Figure 3) at the site of the previous pigmented lesion.
Discusssion
Figure 1. (Ellies) Case 1: Angiogram of the left eye 4 days after LASIK shows macular hemorrhage.
Case 2 A 46-year-old woman had LASIK in the right eye to correct myopia in March 1996. Best corrected visual acuity was 20/80 with a correction of ⫺12.0 D. Fundoscopic examination before surgery revealed a Fuchs’ spot below the right fovea without hemorrhage. A Fuchs’ spot is a fibrovascular scar containing hyperplastic RPE that extends into the retina.1 Preoperative pachymetry was 550 m, and stromal ablation depth was 130 m. The next day, the patient suffered a severe loss of BCVA. An examination revealed a BCVA of worse than 20/200 and a retinal hemorrhage. Fluorescein angiography, performed the following day, revealed a choroidal neovascularization of ap-
Figure 2. (Ellies) Case 1: Angiogram of the left eye 1 month after LASIK shows macular lacquer cracks.
Laser in situ keratomileusis creates 2 kinds of mechanical stress. The first is an increase in IOP (greater than 65 mm Hg) during suction, and the second is an acoustic wave shock during laser ablation.2 Macular hemorrhages in high myopia are mainly associated with choroidal neovascularization and lacquer cracks. The physiopathology of these events is still uncertain. Many authors consider myopic macular changes to be caused by mechanical stretching of the retina and the choriocapillaris within the posterior staphyloma.3,4 In Case 1, the subretinal bleeding could have signaled the development of a new rupture of Bruch’s membrane and choriocapillaris, resulting in lacquer cracks.4,5 In Case 2, choroidal neovascularization was probably present before the surgery. A Fuchs’ spot was noticed at the preoperative examination and the 300 m choroidal neovascularization, 2 days after LASIK. Increased IOP and acoustic wave shock during laser ablation likely provide significant mechanical stress on these markedly fragile globes. This stress may be responsible for the hemorrhage. However, casual association cannot be excluded.
Figure 3. (Ellies) Case 2: Angiogram of the right eye shows choroidal neovascularization 2 days after LASIK.
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CASE REPORTS: ELLIES
The literature reports 4 cases of macular hemorrhage after LASIK6 – 8 and 4 after photorefractive keratectomy.9,10 As did our patients, the patients in these studies presented with poor preoperative BCVA (6 patients worse than 20/40), high myopia, and general thinning of the RPE. Five patients had myopic retinal disease; 4 had Fuchs’ spots and 1 had scleral buckling for retinal detachment. Choroidal neovascularization was confirmed in 2 cases, and lacquer cracks were confirmed in 1 by fluorescein angiography.7 A careful examination of the fundus should be conducted before performing LASIK surgery on highly myopic patients. In cases of similar macular pathology, fluorescein angiography should be done before LASIK. Pre-existing macular pathology, such as choroidal neovascularization and lacquer cracks, could be a new contraindication to LASIK for high myopia.
References 1. Grossniklaus HE, Green WR. Pathologic findings in pathologic myopia. Retina 1992; 12:127–133 2. Janknecht P, Soriano JM, Hansen LL. Cystoid macular oedema after excimer laser photorefractive keratectomy (letter). Br J Ophthalmol 1993; 77:681
924
3. Pruett RC, Weiter JJ, Goldstein RB. Myopic cracks, angioid streaks, and traumatic tears in Bruch’s membrane. Am J Ophthalmol 1987; 103:537–543 4. Klein RM, Green S. The development of lacquer cracks in pathologic myopia. Am J Ophthalmol 1988; 106:282–285 5. Hayasaka S, Uchida M, Setogawa T. Subretinal hemorrhages with or without choroidal neovascularization in the maculas of patients with pathologic myopia. Graefes Arch Clin Exp Ophthalmol 1990; 228:277–280 6. Salah T, Waring GO III, el Maghraby A, et al. Excimer laser in situ keratomileusis under a corneal flap for myopia of 2 to 20 diopters. Am J Ophthalmol 1996; 121: 143–155 7. Kim H-M, Jung HR. Laser assisted in situ keratomileusis for high myopia. Ophthalmic Surg Lasers 1996; 27: S508 –S511 8. Pallikaris IG, Siganos DS. Laser in situ keratomileusis to treat myopia: early experience. J Cataract Refract Surg 1997; 23:39 – 49 9. Loewenstein A, Lipshitz I, Varssano D, Lazar M. Macular hemorrhage after excimer laser photorefractive keratectomy. J Cataract Refract Surg 1997; 23:808 – 810 10. Toda I, Yagi Y, Hata S, et al. Excimer laser photorefractive keratectomy for patients with contact lens intolerance caused by dry eyes. Br J Ophthalmol 1996; 80:604 – 609
J CATARACT REFRACT SURG—VOL 26, JUNE 2000
Macular hemorrhage after laser in situ keratomileusis for high myopia Pierre Ellies, MD, Dominique Pietrini, MD, Livia Lumbroso, MD, Dan A. Lebuisson, MD ABSTRACT We describe 2 women with high myopia of ⫺12.0 and ⫺18.0 diopters who presented with myopic macular hemorrhages 1 and 4 days, respectively, after being treated by laser in situ keratomileusis (LASIK). One hemorrhage was related to a pre-existing choroidal neovascularization and the other to the presence of lacquer cracks. The hemorrhages resolved but resulted in a permanent decrease in vision. A careful fundus examination should be conducted before performing LASIK in highly myopic patients. In cases of similar macular pathology, fluorescein angiography should be done before LASIK. J Cataract Refract Surg 2000; 26:922–924 © 2000 ASCRS and ESCRS
L
aser in situ keratomileusis (LASIK) for high myopia is associated with complications such as a higher incidence of regression and undercorrection. Late appearance of a pseudokeratoconus can be seen. However, macular hemorrhage after LASIK is rare. To the best of our knowledge, although the complication has been reported, it has not been fully described. We present 2 highly myopic patients who developed macular hemorrhages 2 and 6 days, respectively, after LASIK.
Case Reports Both patients had LASIK with an ALK E microkeratome (Chiron), a vacuum pressure of 25 mm Hg, and a suction ring Accepted for publication December 1, 1999. From the Department of Ophthalmology, Hoˆtel-Dieu de Paris Hospital (Ellies), Clinique de la Vision (Pietrini), and Department of Ophthalmology, Pitie´-Salpe´trie`re Hospital, Paris (Lumbroso), and Department of Ophthalmology, Foch Hospital, Suresnes (Lebuisson), France. None of the authors has a financial or proprietary interest in any material or method mentioned. Reprint requests to D. Pietrini, MD, Clinique de la Vision, 55 Avenue Hoche, 75008 Paris, France. E-mail: [email protected]. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
applied until intraocular pressure (IOP) was greater than 65 mm Hg. Two types of laser were used: Case 1, the MEL 60 (Meditec); Case 2, the Keracor 117 (Chiron). A complete ophthalmic examination and corneal videotopography were performed before surgery. Both patients had generalized thinning of the retinal pigment epithelium (RPE), which is characteristic of a myopic fundus.
Case 1 A 32-year-old woman had LASIK in the left eye to correct myopia in May 1996. Best corrected visual acuity (BCVA) before surgery was 20/50 with a correction of ⫺18.0 diopters (D). Preoperative pachymetry was 570 m, and stromal ablation depth was 170 m. Four days after LASIK, the patient had a severe loss of visual acuity in the left eye; BCVA was worse than 20/200. A submacular hemorrhage could be seen on fundoscopy. Fluorescein angiography revealed an area of blocked choroidal and retinal fluorescence corresponding to the hemorrhage (Figure 1). An indocyanine green angiography showed no evidence of choroidal neovascularization. Fluorescein angiography performed 1 month later revealed macular lacquer cracks at the site of the previous hemorrhage and no evidence of subretinal neovascularization. The macular hemorrhage had disappeared (Figure 2). Six months later, BCVA was 20/80 and the fundus unchanged. 0886-3350/00/$–see front matter PII S0886-3350(00)00313-8
CASE REPORTS: ELLIES
proximately 300 m (Figure 3) at the site of the previous pigmented lesion.
Discusssion
Figure 1. (Ellies) Case 1: Angiogram of the left eye 4 days after LASIK shows macular hemorrhage.
Case 2 A 46-year-old woman had LASIK in the right eye to correct myopia in March 1996. Best corrected visual acuity was 20/80 with a correction of ⫺12.0 D. Fundoscopic examination before surgery revealed a Fuchs’ spot below the right fovea without hemorrhage. A Fuchs’ spot is a fibrovascular scar containing hyperplastic RPE that extends into the retina.1 Preoperative pachymetry was 550 m, and stromal ablation depth was 130 m. The next day, the patient suffered a severe loss of BCVA. An examination revealed a BCVA of worse than 20/200 and a retinal hemorrhage. Fluorescein angiography, performed the following day, revealed a choroidal neovascularization of ap-
Figure 2. (Ellies) Case 1: Angiogram of the left eye 1 month after LASIK shows macular lacquer cracks.
Laser in situ keratomileusis creates 2 kinds of mechanical stress. The first is an increase in IOP (greater than 65 mm Hg) during suction, and the second is an acoustic wave shock during laser ablation.2 Macular hemorrhages in high myopia are mainly associated with choroidal neovascularization and lacquer cracks. The physiopathology of these events is still uncertain. Many authors consider myopic macular changes to be caused by mechanical stretching of the retina and the choriocapillaris within the posterior staphyloma.3,4 In Case 1, the subretinal bleeding could have signaled the development of a new rupture of Bruch’s membrane and choriocapillaris, resulting in lacquer cracks.4,5 In Case 2, choroidal neovascularization was probably present before the surgery. A Fuchs’ spot was noticed at the preoperative examination and the 300 m choroidal neovascularization, 2 days after LASIK. Increased IOP and acoustic wave shock during laser ablation likely provide significant mechanical stress on these markedly fragile globes. This stress may be responsible for the hemorrhage. However, casual association cannot be excluded.
Figure 3. (Ellies) Case 2: Angiogram of the right eye shows choroidal neovascularization 2 days after LASIK.
J CATARACT REFRACT SURG—VOL 26, JUNE 2000
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CASE REPORTS: ELLIES
The literature reports 4 cases of macular hemorrhage after LASIK6 – 8 and 4 after photorefractive keratectomy.9,10 As did our patients, the patients in these studies presented with poor preoperative BCVA (6 patients worse than 20/40), high myopia, and general thinning of the RPE. Five patients had myopic retinal disease; 4 had Fuchs’ spots and 1 had scleral buckling for retinal detachment. Choroidal neovascularization was confirmed in 2 cases, and lacquer cracks were confirmed in 1 by fluorescein angiography.7 A careful examination of the fundus should be conducted before performing LASIK surgery on highly myopic patients. In cases of similar macular pathology, fluorescein angiography should be done before LASIK. Pre-existing macular pathology, such as choroidal neovascularization and lacquer cracks, could be a new contraindication to LASIK for high myopia.
References 1. Grossniklaus HE, Green WR. Pathologic findings in pathologic myopia. Retina 1992; 12:127–133 2. Janknecht P, Soriano JM, Hansen LL. Cystoid macular oedema after excimer laser photorefractive keratectomy (letter). Br J Ophthalmol 1993; 77:681
924
3. Pruett RC, Weiter JJ, Goldstein RB. Myopic cracks, angioid streaks, and traumatic tears in Bruch’s membrane. Am J Ophthalmol 1987; 103:537–543 4. Klein RM, Green S. The development of lacquer cracks in pathologic myopia. Am J Ophthalmol 1988; 106:282–285 5. Hayasaka S, Uchida M, Setogawa T. Subretinal hemorrhages with or without choroidal neovascularization in the maculas of patients with pathologic myopia. Graefes Arch Clin Exp Ophthalmol 1990; 228:277–280 6. Salah T, Waring GO III, el Maghraby A, et al. Excimer laser in situ keratomileusis under a corneal flap for myopia of 2 to 20 diopters. Am J Ophthalmol 1996; 121: 143–155 7. Kim H-M, Jung HR. Laser assisted in situ keratomileusis for high myopia. Ophthalmic Surg Lasers 1996; 27: S508 –S511 8. Pallikaris IG, Siganos DS. Laser in situ keratomileusis to treat myopia: early experience. J Cataract Refract Surg 1997; 23:39 – 49 9. Loewenstein A, Lipshitz I, Varssano D, Lazar M. Macular hemorrhage after excimer laser photorefractive keratectomy. J Cataract Refract Surg 1997; 23:808 – 810 10. Toda I, Yagi Y, Hata S, et al. Excimer laser photorefractive keratectomy for patients with contact lens intolerance caused by dry eyes. Br J Ophthalmol 1996; 80:604 – 609
J CATARACT REFRACT SURG—VOL 26, JUNE 2000